Clinical UM Guideline

 

Subject: Treatment of Hyperhidrosis
Guideline #: CG-MED-63 Publish Date:    10/17/2018
Status: Reviewed Last Review Date:    09/13/2018

Description

This document addresses various treatments of hyperhidrosis, a condition characterized by excessive sweating.

Note: For information regarding the use of botulinum toxin for the treatment of hyperhidrosis, please see:

Note: For information regarding other uses for the technologies addressed in this document, please see:

Clinical Indications

Medically Necessary:

Iontophoresis is considered medically necessary in the treatment of primary or secondary hyperhidrosis only for individuals who have tried prescription strength antiperspirants without success and meet any ONE of the following criteria:

  1. Presence of medical complications or skin maceration with secondary infection; or
  2. Significant functional impairment, as documented in the medical record.

Treatment of primary axillary or palmar hyperhidrosis with endoscopic thoracic sympathectomy is considered medically necessary in the small subset of individuals with hyperhidrosis where both of the following criteria (1 and 2) have been met:

  1. It has been adequately documented that all efforts at nonsurgical therapy have failed; and
  2. Either of the following:
    1. Presence of medical complications or skin maceration with secondary infection; or
    2. Significant functional impairment, as documented in the medical record.

Not Medically Necessary:

Treatment of hyperhidrosis is considered not medically necessary when the above criteria are not met.

Treatment of plantar hyperhidrosis with thoracic or lumbar sympathectomy or sympathetic block is considered not medically necessary in all cases.

All other therapies for hyperhidrosis are considered not medically necessary, including but not limited to:

  1. Axillary liposuction; or
  2. Laser treatment; or
  3. Microwave energy; or
  4. Resection of axillary sweat glands.
Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Iontophoresis

CPT

 

97033

Iontophoresis, each 15 minutes

 

 

HCPCS

 

E1399

Durable medical equipment, miscellaneous [when specified as iontophoresis device for home use]

 

 

ICD-10 Diagnosis

 

L74.510-L74.519

Primary focal hyperhidrosis

L74.52

Secondary focal hyperhidrosis

R61

Generalized hyperhidrosis

Sympathectomy

CPT

 

32664

Thoracoscopy, surgical; with thoracic sympathectomy

 

 

ICD-10 Procedure

 

01BL3ZZ

Excision of thoracic sympathetic nerve, percutaneous approach

01BL4ZZ

Excision of thoracic sympathetic nerve, percutaneous endoscopic approach

 

 

ICD-10 Diagnosis

 

L74.510

Primary focal hyperhidrosis, axilla

L74.512

Primary focal hyperhidrosis, palms

 

Note: sympathectomy for the following hyperhidrosis diagnoses is considered Not Medically Necessary:

L74.511

Primary focal hyperhidrosis, face

L74.513

Primary focal hyperhidrosis, soles

L74.519

Primary focal hyperhidrosis, unspecified

L74.52

Secondary focal hyperhidrosis

R61

Generalized hyperhidrosis

Other procedures

CPT

 

15876-15879

Suction assisted lipectomy [includes codes 15876, 15877, 15878, 15879]

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as laser or microwave destruction or resection of subcutaneous sweat glands]

64520

Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)

64818

Sympathectomy, lumbar

64999

Unlisted procedure, nervous system [when specified as endoscopic lumbar sympathectomy]

 

 

ICD-10 Procedure

 

01BN0ZZ

Excision of lumbar sympathetic nerve, open approach

01BN3ZZ

Excision of lumbar sympathetic nerve, percutaneous approach

01BN4ZZ

Excision of lumbar sympathetic nerve, percutaneous endoscopic approach

0X040ZZ-0X044ZZ

Alteration of right axilla [by approach; includes codes 0X040ZZ, 0X043ZZ, 0X044ZZ]

0X050ZZ-0X054ZZ

Alteration of left axilla [by approach; includes codes 0X050ZZ, 0X053ZZ, 0X054ZZ]

 

 

ICD-10 Diagnosis

 

 

Note: procedures listed above are considered Not Medically Necessary for the following diagnoses:

L74.510-L74.519

Primary focal hyperhidrosis

L74.52

Secondary focal hyperhidrosis

R61

Generalized hyperhidrosis

Discussion/General Information

Background/Overview

Hyperhidrosis is a relatively uncommon condition of exaggerated perspiration due to excessive secretion of the eccrine sweat glands in amounts greater than required for physiologic needs of thermoregulation and electrolyte alteration.  Primary hyperhidrosis is idiopathic in nature, typically involving the hands (palmar), feet (plantar) or armpits (axillae).  Secondary hyperhidrosis can result from a variety of drugs, such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), or underlying disease/conditions, such as febrile disease, diabetes mellitus or menopause.  Gustatory hyperhidrosis may be primary or secondary in nature, but is usually considered separately from these two classes of hyperhidrosis.  As a primary condition, it is characterized by excessive sweating of the lips, nose, and forehead after eating certain foods.  As a secondary condition, this sweating condition is the result of complications from surgery to the parotid gland and subsequent aberrant regenerating parasympathetic fibers.

The consequences of hyperhidrosis are primarily psychosocial in nature.  Excessive sweating may be socially embarrassing, may require several changes of clothing a day or result in staining of clothing or shoes.  In some situations, hyperhidrosis may interfere with the activities of daily living.  For example, palmar hyperhidrosis may interfere with those jobs that require detailed work with the hands.

Treatment of secondary hyperhidrosis naturally focuses on treatment of the underlying cause.  A variety of therapies have been investigated for primary hyperhidrosis, including topical therapy with aluminum chloride or tanning agents, iontophoresis, and endoscopic transthoracic sympathectomy. 

Description of Technologies

Aluminum Chloride: Aluminum chloride is a common component of over-the-counter antiperspirants, although a prescription product is available (Drysolâ).  Aluminum chloride inhibits sweating by shrinking the secretory cells in sweat glands.  Aluminum chloride is predominantly used to treat axillary hyperhidrosis and not palmar or pedal hyperhidrosis.  Such aluminum chloride-based antiperspirants need to be applied directly to the affected area of skin once a week.

Iontophoresis: This therapy involves the introduction of an electrical current through the skin using water as a medium.  Iontophoresis is a long-standing treatment of palmar or plantar hyperhidrosis and more recently axillary primary hyperhidrosis, with a reported success rate of up to 85%.  The mechanism of action is not precisely known, but is thought to be related to plugging of the sweat gland pores.  The typical device consists of water-filled trays containing electrodes.  The individual inserts the hands or feet or positions the device in the axilla, and the current is turned on.  Individuals are treated for approximately 20 minutes, with treatments every 2 to 5 days for 5 to 10 sessions before an effect is observed.  Maintenance therapy may be required every 2 weeks after a normal level of sweating is achieved.  Treatment may be uncomfortable and in some cases painful.  Several iontophoresis devices have been approved by the FDA.  There are some machines that can only be used by physicians in an office setting.  However, there are currently two commercially available machines intended for home use by individuals with a prescription.  These devices are the Drionicâ device (General Medical Co., Los Angeles, CA) and the Fisher™ MD-1a Galvanic Unit (R.A. Fischer Co., Northridge, CA.).

Pharmacologic Therapy: Some classes of drugs, including anticholinergics and some anti-inflammatory agents have been identified to help with this condition.  These drugs work by either interfering with the function of the sympathetic nervous system or in other ways altering the function of the body to decrease perspiration.  The use of drugs is common in conjunction with iontophoresis therapy.

Sympathectomy: Sympathectomy involves the surgical cutting of the nerve that stimulates sweat glands.  This surgical procedure can be done openly or endoscopically and is usually reserved for palmar, axillary, and craniofacial hyperhidrosis.  Although successful results have been reported to be up to 95% in some studies, significant complications have been noted.  Such complications include worsening of hyperhidrosis symptoms, gustatory hyperhidrosis, wound infection, puncture of the chest wall, and several complications involving the nerves of the ribs.

Laser therapy: As with many other skin-related conditions, lasers have been proposed for the destruction of subcutaneous sweat glands.  Laser therapy has been proposed as a method to treat hyperhidrosis by disrupting the cellular integrity of sweat glands.  At this time, there is insufficient evidence to determine whether or not this treatment method is effective.

Microwave: This treatment method involves the use of a microwave emitting device that applies microwave energy to superficial skin structures.  The intent is to destroy the sweat glands under the skin.  At this time, there is insufficient evidence to determine whether or not this treatment method is safe or effective.

Rationale

The medical necessity of treatment for hyperhidrosis focuses on those cases that result in significant functional impairment including medical complications, such as skin maceration or interference with activities of daily living.  The following therapies have been shown to be effective in the treatment of hyperhidrosis.

Sympathectomy

The available evidence addressing the use of either thoracic or lumbar sympathectomy for the treatment of plantar hyperhidrosis is extremely limited.  The most robust study published to date included 30 women randomized to receive either thoracic sympathectomy or no surgical intervention (Loureiro, 2008).  The authors reported 20% of surgical subjects suffered prolonged post-operative pain, and that 53.3% experienced significant worsening compensatory hyperhidrosis (CH).  The largest study available was published by Reiger et al. (2011), who conducted a retrospective case series study involving 130 subjects with palmoplantar hyperhidrosis previously treated with thoracic sympathectomy.  All subjects had 100% success with their palmar hyperhidrosis with their previous procedures, but their plantar condition persisted.  Endoscopic lumbar sympathectomy was used to resect the second, third, and fourth lumbar ganglia in female subjects, and male subjects had only the third and fourth lumbar ganglia resected to avoid ejaculation disorders.  A total of 260 sympathectomies were performed for all 130 subjects.  Anhidrosis was reported in 248 of 260 feet (95%), and residual slight sweating in 12 feet (12%) immediately after sympathectomy.  Mean follow-up was 37 months (range 3-90 months).  Thirty-four subjects (26%) were lost to follow-up.  Of the remaining 96 subjects, plantar hyperhidrosis was eliminated in 93 (97%), but recurred on one side in 3 subjects (3%).  Persistent or recurrent slight moisture was observed in 22 subjects.  Bromhidrosis (body odor) was eliminated in 37 of the 41 subjects (91%) reporting that condition at baseline.  After lumbar sympathectomy, 24 subjects (25%) reported new slight CH or increased severity of existing CH.  New, severe CH was not reported in any subject.  Eighteen subjects (18%) reported temporary neuralgia that had completely resolved at the time of final visit.  No erectile or ejaculatory complications were reported at any time point.  This retrospective study had a high loss to follow-up rate, with over a quarter of the subjects not completely followed.  Limitations of this study include its uncontrolled, retrospective design and high drop-out rate.

Neumayer and others conducted a study that included 73 subjects, 66 of whom had plantar hyperhidrosis (2005).  Subjects in this study were treated with an endoscopic thoracic sympathectomy.  The authors reported that 42% of participants had significant improvements in their conditions, with 42.4% having no changes.  Interestingly, 15.2% of participants had exacerbated symptoms postoperatively.  CH occurred in 19.4% of subjects and 31.9% had gustatory sweating.  Kim et al. reported the results of a series of 69 subjects with plantar hyperhidrosis treated with chemical lumbar sympathetic block (2008).  Of the 138 procedures completed, successful treatment was seen in 72.2% of subjects.  Complications included temporary sexual dysfunction in 1 subject, CH in another, and significant post-block pain in 3 subjects.

A large case series study of endoscopic lumbar sympathectomy was published by Reisfeld and others in 2013.  This study involved 154 subjects who underwent outpatient endoscopic lumbar sympathectomy (ELS) for the treatment of plantar hyperhidrosis.  Sympathectomy was conducted at the third lumbar vertebrae in 68.2% of subjects and at the fourth lumbar vertebrae in 31.8%.  Follow-up averaged 15 months and ranged up to 4.7 years.  The authors reported that anhidrosis was achieved in 97.4% of subjects with the remainder reporting major reduction in symptoms.  There were two surgical complications reported, including lymphatic leak and misidentification of genitofemoral nerve for sympathetic nerve.  Six early subjects required conversion to an open surgical procedure.  Partial recurrence was reported in 4.5% of subjects, with 2.6% requiring revision surgery.  The authors concluded that severe plantar hyperhidrosis can be safely and effectively treated by endoscopic lumbar sympathectomy using the clamping method on an outpatient basis with low morbidity and complete resolution of symptoms.  However, it should be noted that while this study was the largest of its kind yet published; additional studies are warranted to evaluate the safety and efficacy of lumbar sympathectomy.

Other smaller case series studies have been conducted.  Rieger and colleagues studied 8 subjects who underwent lumbar sympathectomy for plantar hyperhidrosis (2007).  A large proportion of study subjects experienced CH (62%) and 50% had post-operative neuralgia.  A study by Singh and colleagues discussed a small trial of thoracic sympathectomy in 49 participants with plantar hyperhidrosis (2002).  The authors reported a 90% success rate in treating plantar hyperhidrosis, with a 13% rate of CH.  Additionally, Jani described a series of 7 subjects who underwent lumbar sympathectomy (2009).  The authors did not adequately report the outcome of the procedure in terms of successful treatment of the plantar hyperhidrosis, but did report 1 subject with spontaneously resolving upper thigh parasthesias.  No CH was reported.

Singh and colleagues (2016) reported on a retrospective case series study involving 10 subjects with plantar hyperhidrosis treated with 20 lumbar sympathectomy procedures.  The authors reported no adverse events in the immediate postoperative period.  Plantar anhidrosis was achieved in all subjects at the first follow-up visit.  However, 2 participants (20%) suffered a relapse.  The first subject had minimal recurrence at 14 months, and the second subject had recurrence at 15 months and underwent a repeat procedure.  Compensatory sweating of the back was reported in 3 subjects (30%), although symptoms were reported as minimal and required no treatment.  One subject had compensatory gustatory sweating as well.  Two subjects (20%) developed unilateral post-sympathetic neuralgia affecting the thigh and leg; the pain affected the right leg and thigh in both and resolved within 6 months.  No ejaculatory dysfunction was reported in the 2 male subjects.

In 2017 Elalfy described the use of a new procedure, sequential extended thoracoscopic sympathicotomy (SETS), for the treatment of palmo-axillo-plantar hyperhidrosis.  SETS targets the same sympathetic ganglion targeted in the standard approach (L1 to L2) and additionally targets ganglion at T10 to T12.  Nerve destruction was with either electrocautery or harmonic scalpel.  The study involved 42 subjects with a minimum 24 month follow-up data, and post-procedure visits were conducted monthly for the first 6 months and then every 3 months through the next 18 months.  At 24 months, visual analog scale assessments resulted in significant improvement in palmar, axillary, and plantar symptoms (p<0.0001 for all).  Likewise, iodine-starch testing demonstrated significant improvements at all three locations, with no sweating detected at the axillar or palmar sites, and 28% of subjects having positive tests at the plantar sites (p<0.0001 for all).  The authors reported 12 complications (28.6%), with pneumothorax in 2 subjects, mild rebound hyperhidrosis in 3 subjects, 3 subjects with compensatory hyperhidrosis in the groin region and mild intercostal neuralgia of 1 week duration, surgical emphysema, and Horner syndrome in one subject each.  They concluded that the SETS method appeared to provide satisfactory results, but prospective studies were needed to fully evaluate efficacy.

Overall, the available body of evidence addressing lumbar and thoracic sympathectomy for plantar hyperhidrosis is weak, but the evidence addressing the thoracic procedure is stronger than that for lumbar procedures.  For thoracic procedures, the evidence is better, and indicates a much lower incidence of complications and recurrence, and it has become widely accepted as a standard of care procedure for severe cases when conservative measures have failed.  On the other hand, the evidence addressing the use of endoscopic lumbar sympathectomy had not demonstrated that the safety and efficacy is equal to or better than alternative treatments.  The available data indicates a high rate of complications and no long-term results have been presented. 

Liposuction

The available evidence addressing surgical excision or liposuction of axillary tissues has not established the safety or efficacy when compared to alternative treatments.  Ibrahim and colleagues reported on the largest and only controlled study of suction-curettage for the treatment of focal axillary hyperhidrosis (2013).  In this single-center, parallel-group control trial, 20 subjects were randomly assigned to either left or right axillary botulinum toxin injection or suction-curettage to the contralateral axilla.  At 3 months post-treatment, botulinum toxin injections decreased baseline resting sweat production by 72.1% vs. 60.4% for suction-curettage, (p=0.29) and baseline exercise-induced sweat production by 73.8% vs. 58.8% (p=0.10).  Using a stratification scheme of light vs. heavy sweaters, exercise-induced sweat production was lower by 10.48 mg/min or 34.3% at botulinum toxin-treated sites (p=0.0025).  Compared with suction-curettage, botulinum toxin subjects had greater improvements in quality of life by 0.80 points (p=0.0002) and 0.90 points (p=0.0017) at 3 and 6 months post-treatment, respectively, as measured by the Hyperhidrosis Disease Severity Scale (HDSS).  The authors concluded that at 3 months, neurotoxin injections are more effective than suction-curettage in all cases and markedly more effective in heavy sweaters.  The other published literature addressing surgical excision and liposuction of axillary sweat glands is limited to case reports (Shachor, 1994; Shelley, 1998; Shenq, 1987; Swinehart, 2000; Tsai, 2001). 

Laser therapy

The use of laser therapy has been proposed as a treatment of axillary hyperhidrosis.  At this time, a limited number of small studies have been published addressing this treatment method.  One study investigated the use of a 1046 nm Nd-YAG laser to subcutaneously treat the axillary region (Goldman, 2008).  This study included 17 subjects with axillary hyperhidrosis who had laser energy delivered subcutaneously via a fiber optic device through an 18 gauge needle.  The authors reported that histologic examination demonstrated microvesiculation, decapitation and dilatation of eccrine glands after laser treatment.  Physician’s global assessment was excellent in 10 subjects (58.8%), good in 4 (23.5%), and fair in 3 (17.6%), resulting in 82.3% of good or better outcomes.  No objective measures of long-term outcome were reported.  Adverse effects were limited, transient, and mild, including burns (1), seroma (1), relapse of hyperhidrosis (1), and temporary hair loss (8).  No serious complications, such as bleeding, damage to axillary plexus, or deeper structures, were noted.  During follow-up, a temporary decline in the sensitivity of the treated area was reported by all subjects.  The decreased sensitivity lasted about 3 to 5 weeks and spontaneously resolved in all cases.

Another study enrolled 6 subjects undergoing treatment with a Nd:YAG 1064 nm laser at hair reduction settings (Letada, 2012).  Three subjects completed the 3-month follow-up period.  The authors reported that patient-reported survey results found marked improvement in axillary sweating.  Modified starch-iodine test results supported this finding at 1 month.  Another unblinded case series study was by Bechara and colleagues (2012) and involved 19 subjects who underwent treatment with an 800 nm diode laser.  In this study, subjects acted as their own controls with one side randomly treated with laser therapy and the other side not treated.  The results demonstrated that both treated and untreated sides significantly improved after treatment, but no significant difference between sides was noted.  In both studies, no adverse events were reported and no significant changes in the histology of punch biopsy samples were noted. 

These initial small studies demonstrate conflicting results, perhaps due to the different laser types used.  The efficacy and safety of this treatment for hyperhidrosis has not been established compared to alternative treatments options.

Microwave therapy

The use of microwave therapy has been described in two peer-reviewed published studies.  These devices deliver microwave energy to superficial skin structures to cause thermolysis of eccrine and apocrine sweat glands.  The first, by Hong and others (2012), was a case series which included 26 subjects with primary axillary hyperhidrosis who underwent treatment with the miraDry® microwave system (Miramar Labs; Sunnyvale, CA).  Subjects were followed for 12 months.  Primary outcomes were measured with the Hyperhidrosis Disease Severity Scale (HDSS) and secondary outcomes were measured with gravimetric (sweat production) testing.  The primary efficacy measure was the percentage of subjects that reduced their HDSS scores from 3 or 4 (barely tolerable or intolerable sweating) at baseline to 1 or 2 at follow-up visits.  The HDSS data showed a 90% or higher improvement at all follow-up time points.  At the 12-month measurement, 9% (29/31) of subjects had at least a 1 point drop in HDSS scores and 55% (17/31) had a 2 point drop.  These results were supported by the secondary outcome measure, with 90% of subjects having at least a 50% drop in gravimetric measurement at 12 months.  With regard to adverse events; edema, redness, vacuum acquisition marks, and post-treatment discomfort were reported in over 84% of subjects and were self-limited.  Palpable bumps under the skin were reported by 71% of subjects, altered skin sensation by 65% of subjects, and axillary hair loss was reported by 26% of subjects.  One subject reported neuropathy of the left arm with associated muscle weakness.  This subject showed improvement at 6 months after treatment, but was lost to follow-up.  There was no confirmation that this adverse neurologic event had resolved. 

In another microwave study (DTS G2 System; Miramar Labs, Sunnyvale, CA), Glasser et al. reported the results of a double-blind randomized controlled study in which 120 subjects with primary axillary hyperhidrosis were assigned in a 2:1 fashion to either microwave therapy (n=81) or sham treatment (n=39).  Subjects were required to have an HDSS score of 3 or 4 with baseline axillary sweat production of greater than 50 mg/5 min as measured by gravimetric readings.  Subjects were excluded if they had prior surgery or botulinum toxin injections within the past 12 months.  Twenty (17%) subjects did not complete the study to the 30-day follow-up time point.  The authors reported 89% of treatment subjects and 54% of controls met the primary endpoint of HDSS measurement drop of 1 or 2 points at 30 days post-treatment.  The microwave treatment group had significantly more improvement in HDSS compared to the sham group (p<0.001).  HDSS measurements at 6 months were still significantly in favor of the microwave group, with 67% with a score of 1 or 2 vs. 44% in the sham group  (p=0.02).  Twelve month data were only available for the microwave group, with 69% reporting a HDSS score or 1 or 2.  Adverse events reported in the microwave group included altered sensation in the treated limb (10%), pain (6%), swelling (5%), blisters or burns (5%), skin rash (5%), skin nodules or bumps (2%), and CH (2.5%).  One subject with CH did not have resolution by the end of the study.  The authors noted that study data provided an opportunity to identify areas for improvement of the treatment protocol including waiting longer between treatments and using a higher dose of energy at the second session.  The results of these studies show promise, but the rate of adverse events and efficacy have not established equivalency to other treatment options.

Definitions

Eccrine gland: A gland in the skin that secretes sweat. These glands are located all over the body, and greater concentrations may be found in certain areas of the body such as the armpits, feet, and hands.

Hyperhidrosis: Severe and uncontrollable localized sweating of the scalp, torso (truncal), face (facial) hands (palmar), underarms (axillary), or the feet (plantar or pedal).

Iontophoresis: The passing of an ionized substance through intact skin by the application of a direct electrical current.

Liposuction: A surgical approach that uses a vacuum to remove fatty tissue from under the skin.

Primary hyperhidrosis: Hyperhidrosis due to unknown causes.

Secondary hyperhidrosis: Hyperhidrosis that results from an underlying cause; some common causes include prescribed drug side-effects and medical conditions such as anxiety disorders, diabetes mellitus, and menopause.

Secondary gustatory hyperhidrosis: A nervous system disorder characterized by severe sweating of the forehead, upper lip and mouth region, or chest that may result from exposure to spicy foods and complications from surgery to the parotid gland.

Sympathectomy: A surgical procedure during which segments of the sympathetic nerves that stimulate sweating are cut. This procedure interrupts the nerve transmissions that lead to excessive sweating.

References

Peer Reviewed Publications:

  1. Bachmann K, Standl N, Kaifi J, et al. Thoracoscopic sympathectomy for palmar and axillary hyperhidrosis: four-year outcome and quality of life after bilateral 5-mm dual port approach. Surg Endosc. 2009; 23(7):1587-1593.
  2. Bechara FG, Georgas D, Sand M, et al. Effects of a long-pulsed 800-nm diode laser on axillary hyperhidrosis: a randomized controlled half-side comparison study. Dermatol Surg. 2012; 38(5):736-740.
  3. Drott C, Gothberg G, Claes G. Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol. 1995; 33(1):78-81.
  4. Elalfy K, Emile S, Elfeki H, et al. Sequential extended thoracoscopic sympathicotomy for palmo-axillo-plantar hyperhidrosis. Ann Thorac Surg. 2017; 104(4):1200-1207.
  5. Glaser DA, Coleman WP 3rd, Fan LK, et al. A randomized, blinded clinical evaluation of a novel microwave device for treating axillary hyperhidrosis: the dermatologic reduction in underarm perspiration study. Dermatol Surg. 2012; 38(2):185-191.
  6. Hong HC, Lupin M, O'Shaughnessy KF. Clinical evaluation of a microwave device for treating axillary hyperhidrosis. Dermatol Surg. 2012; 38(5):728-735.
  7. Ibrahim O, Kakar R, Bolotin D, et al. The comparative effectiveness of suction-curettage and onabotulinumtoxin-A injections for the treatment of primary focal axillary hyperhidrosis: a randomized control trial. J Am Acad Dermatol. 2013; 69(1):88-95.
  8. Jani K. Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis. J Am Coll Surg. 2009; 209(2):e12-15. 
  9. Kim WO, Yoon KB, Kil HK, Yoon DM. Chemical lumbar sympathetic block in the treatment of plantar hyperhidrosis: a study of 69 patients. Dermatol Surg. 2008; 34(10):1340-1345.
  10. Lawrence CM, Lonsdale Eccles AA. Selective sweat gland removal with minimal skin excision in the treatment of axillary hyperhidrosis: a retrospective clinical and histological review of 15 patients. Br J Dermatol. 2006; 155(1):115-118.
  11. Letada PR, Landers JT, Uebelhoer NS, Shumaker PR. Treatment of focal axillary hyperhidrosis using a long-pulsed Nd:YAG 1064 nm laser at hair reduction settings. J Drugs Dermatol. 2012; 11(1):59-63.
  12. Levit F. Treatment of hyperhidrosis by tap water iontophoresis. Cutis. 1980; 26(2):192-194.
  13. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopy thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery. 2002; 51(5 Suppl):S84-87.
  14. Loureiro Mde P, de Campos JR, Kauffman P, et al. Endoscopic lumbar sympathectomy for women: effect on compensatory sweat. Clinics (Sao Paulo). 2008; 63(2):189-196.
  15. Miller D, Force S. Temporary thoracoscopic sympathetic block for hyperhidrosis. Ann Thorac Surg. 2008; 85(4):1211-1214.
  16. Neumayer C, Panhofer P, Zacherl J, Bischof G. Effect of endoscopic thoracic sympathetic block on plantar hyperhidrosis. Arch Surg. 2005; 140(7):676-680.
  17. Ong WC, Lim TC, Lim J, et al. Suction curettage; treatment for axillary hyperhidrosis and hidradenitis. Plast Reconstruct Surg. 2003; 111(2):958-959.
  18. Park S. Very superficial ultrasound-assisted lipoplasty for the treatment of axillary osmidrosis. Aesth Plast Surg. 2000; 24(4):275-279.
  19. Reisfeld R, Pasternack GA, Daniels PD, et al. Severe plantar hyperhidrosis: an effective surgical solution. Am Surg. 2013; 79(8):845-853.
  20. Rieger R, Loureiro Mde P, Pedevilla S, de Oliveira RA. Endoscopic lumbar sympathectomy following thoracic sympathectomy in patients with palmoplantar hyperhidrosis. World J Surg. 2011; 35(1):49-53.
  21. Rieger R, Pedevilla S. Retroperitoneoscopic lumbar sympathectomy for the treatment of plantar hyperhidrosis: technique and preliminary findings. Surg Endosc. 2007; 21(1):129-135.
  22. Rodriguez PM, Freixinet JL, Hussein M, et al. Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients. Eur J Cardiothorac Surg. 2008; 34(3):514-519.
  23. Shachor D, Jedeikin R, Olsfanger D, et al. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. A review of 290 sympathectomies. Arch Surg. 1994; 129(3):241-244.
  24. Shenaq SM, Spria M, Christ J. Treatment of bilateral axillary hyperhidrosis by suction assisted lipolysis technique. Ann Plast Surg. 1987; 19(6):548-551.
  25. Singh S, Kaur S, Wilson P. Early experience with endoscopic lumbar sympathectomy for plantar hyperhidrosis. Asian J Endosc Surg. 2016; 9(2):128-134.
  26. Singh B, Shaik AS, Moodley J, et al. Limited thoracoscopic ganglionectomy for primary hyperhidrosis. S Afr J Surg. 2002; 40(2):50-53.
  27. Swinehart JM. Treatment of axillary hyperhidrosis: combination of the starch-iodine test with the tumescent liposuction technique. Dermatol Surg. 2000; 26(4):392-396.
  28. Tsai RY, Lin JY. Experience of tumescent liposuction in the treatment of osmidrosis. Dermatol Surg. 2001; 27(5):446-458.
Index

Drionic
Drysol
Fisher MD-1a Galvanic Unit
Hyperhidrosis
Iontophoresis
miraDry

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed

09/13/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Removed Websites for Additional Information section. Updated discussion section.

New

11/02/2017

MPTAC review. Initial document development. Moved content of MED.00032 Treatment of Hyperhidrosis to new clinical utilization management guideline document with the same title.